Part 3: p 19-27 Flashcards
What was event-free survival rate
How effective is PTCA in comparison to exercise for stable CAD ?
Hambrecht study Circulation 2004:109(11):1371-1378
BR 20
Hambrecht study Circulation 2004:109(11):1371-1378
P - Males (n=101) with stable CAD (angina + 1 coronary stenosis > 75%)
I - 12 months of bicycle ergometer at 70% maximal heart rate for 20 min/day and one 60 minute group exercise session per week. (total 3 hrs exercise/week)
C - PCI (stent) with ASA 100 mg longterm and plavix 75 mg/d x 4 weeks.
Outcomes (multiple) freedom from vascular events
T - 12 months
Results -
1) “Exercise had an event-free survival rate that was 26% better (relative rate)”
2) Absolute event free rate was 88% for exercise and 70% for PCI group (P=0.02)
3) Absolute difference = 18%, NNT = 5.5
BR 20
- this was a comparison of first line treatments
In Dr Jenkins RCT of the PORTFOLIIO diet of cholesterol lowering foods vs lovastatin, what were the significant results ?
P: (n=46) healthy hyperlipidemic adults randomized for 1 month to:
I: a) Very low SATURATED fat diet (based on whole wheat & low fat dairy)
Very low SATURATED fat diet + lovastatin 20 mg/day
b) Portfolio diet - high in plant Sterols, Soy protein, viScous fibers & almonds.
C: Very low saturated diet + Placebo
O1: Overall the effects of the portfolio diet were the same as the lovastatin (control vs statin vs portfolio):
a) LDL-C drop: 8% v 31% v 29% (P<0.005 both interventions vs control)
b) CRP drop: 10% vs 33% vs 28% (P<0.005 both interventions vs control)
c) Total cholesterol 6% vs 23% vs 22% (P<0.005 both interventions vs control)
Conc from abstract “the diversifiying of cholesterol-lowering components with the Portfolio diet increased the effectiveness of diet as a treatment of hypercholesterolemia)
BR 20, JAMA 2003:290(4):502-10
Give examples of the effectiveness of lifestyle medicine to lower health care costs
1) In the Diabetes Prevention Program & Diabetes Prevention Program Outcomes Study while more expensive than placebo intervention, the cost of lifestyle (& metformin) were offset by reductions in costs of non-intervention related medical care (Clinical Diabetes & Endocrinology 2015:1(1):9)
2) The CHIP program at Vanderbilt University for diabetics found: a) Positive changs in HbA1c and cholesterol results & self-reported physical health and well-being, b) Health care costs were substantially reduced for study participants (vs non-participant group), c) Approx 24% of study participants were able to eliminate one or more of their medications. Shurney D J Managed Care Medicine 2012:15(4):5-10.
Name 4 biological processes affected by a healthy lifestyle
BR 21
A healthy lifestyle affects:
1) Reduces chronic Systemic inflammation
2) Reduces insulin resistance (the underliying cause of Hyperglycemia & related metabolic dysfunction)
3) Provides Antioxidants
4) Gene expression (epigenetics)
Mnemonic - ‘SHAG’ (as in rug)
BR 21
What types of diseases can benefit from lifestyle interventions such as smoking cessation, increased physical activity, and making dietary changes ?
BR 21
Strong evidence fomr Cochrane collaboration, American Heart Association and US Preventative Task Force that these interventions can decrease morbidity and mortality from:
1) Cardiovascular disease
2) Cerebral vascular disease
3) Cancer in adults.
BR 21
What proportion (and #) of cancers could be prevented in the US
1) 1/3 of the most common cancers in the US could be prevented.
2) This is 340,000 preventable cancers per year
BR 21 ref 58
- from elsewhere in BR book, 1/3 of cancers related to smoking, 1/10 of cancers related to EtOH.
What are the 4 main lifestyle factors to prevent 1/3 of cancers in the USA ?
BR 21 ref 58
1) Use of Tobacco & alcohol
2) Obesity
3) Lack of physical Activity
4) Dietary factors
Mn - ‘TOAD’ saying ‘1/3 of cancer’
BR 21 ref 58
Even is someone is not overweight, name 4 major causes of morbidity and mortality which a poor diet places them at risk for
1) Vascular - Coronary heart disease, stroke, hypertension
2) Type 2 diabetes
3) Osteoporosis
4) Some cancers
BR 21 ref 59
Based on a 2002 quantitative review article,
1) How effective are behavioral interventions at changing dietary fat intake & intake of fruits & vegetables
2) what population(s) were most responsive ?
3) Name 2 promising interventions
(optional question)
BR21
Ammerman AS Prev Med 2002:35(1):25-41
After reviewing 92 independent studies to change diet concluded:
1) 77% of studies reported significant increase in fruit & vegetable intake (average increase 0.6 servings/day)
2) Similar results with intake of calories from fat with average 7% reduction in calories from fat
3) Greater success rate in populations at risk of (or Dx with) disease than among the general population
4) Two promising interventions:
Goal setting
Small groups
BR 21 ref 59
What were the findings in a study (by Merrill et al of the CHIP program) after an 18 month intervention (4 week educational course and followup meetings) in terms of the maintenance of healthy behaviors
BR 21 ref 60
1) Improvement was better at 6 weeks than at 18 mos
2) At 18 mos there were still sustained improvments above baseline in over 50% of the participants in the following categories:
LOWER intake of calories & saturated fat
MORE physicial activity
GREATER intake of: fruits + vegetables and dietary fiber
BR 21 ref 60
Describe the INTERSTROKE study
Context: How risk factors from unhealthy behaviours influence health outcomes
BR 22
Yusuf S, Lancet 2016:388(10046)761-775.
Design: International case-control study
Population: 26,919 subjects (13,447 with stroke [ischemic & hemorrhagic], 13,472 controls) with acute first stroke.
- from 32 countries in Asia, American, Europe, Australia, Middle East, Africa
- Looked at odds ratios of multiple risk factors for stroke and population attributable risk (PAR).
- all 10 risk factors account for 90% of PAR in men & women.
- similar associations noted in men/women, old/young, all regions of the world.
Mnemonic: ESCAPED
E - Exercise
S - Smoking
C - CV - Htn, lipids, cardiac (afib)
A - Alcohol
P - Stress
E - Endo - DM, waist-hip ratio
D - Diet
Describe the INTERHEART study
Context: How risk factors from unhealthy behaviours influence health outcomes
BR 21
Yusuf S, Lancet 2004:364(9438):937-952
Summary here
Population: 15,000 cases of acute MI from 52 countries and 14,800 controls (total 29,972).
- Looked at odds ratios of multiple risk factors for MI and population attributable risk (PAR).
- all 9 risk factors account for 90% of PAR in men & 94% in women.
- Psychosocial factors (stress) accounted for PAR 32%
- similar associations noted in men/women, old/young, all regions of the world.
Mnemonic: ESCAPED
E - Exercise
S - Smoking
C - CV - Htn, lipids - Htn
A - Alcohol
P - Stress
E - Endo - DM, obese
D - Diet
1) What was the Framingham heart study ?
2) What did it show in terms of the risk of CVD events ?
3) What was the difference in median life expectancy of men/women with optimal vs >=2 risk factors
(BR 23)
A prospective cohort study to estimate the risk of cardiovascular disease.
P: Cohort of 7,926 men & women free of heart disease at 50 yo, followed to 95 yo (112,000 person yrs of FU)
Found risk of CVD events of those with optimal vs >=2 risk factors was:
- Men: 5% vs 69%, (average 52%; median survival 30yrs)
- Women: 8% vs 50% (average 39%; med survival 36 yrs)
3) Those with optimal risk factors lived about 10 yrs longer (BR 23)
Mnemonic
Men: 5 - 50 - 70
Women: 8 - 40 -50
Framingham 10 yr risk calculator here
Full list of RFs;
Decent - Diabetes
Score/study - Systolic BP
Helping - Hypertension
To - Total Chol
Save - Smoking
Atherosclerotic - Age
Hearts - HDL
In terms of CV risk factors & CV & total mortality
What did the MRFIT and related cohort studies show ?
What did it teach us re lipids & CV Death ?
Stamler J JAMA 2000:284:311-318
BR 23
Multiple Risk Factor Intervention Trial
In cohorts of young men (30-37 yrs) followed for 16-34 yrs:
1) People with low risk factor status (Htn, smoking, [Chol]) had:
a) 80% lower risk for CV disease mortality
b) 50% lower TOTAL mortality
c) 6-10 yrs greater life expectancy
2) In 3 cohort studies of young men, those with [Chol-T] > 240 mg/dL (6.2 mmol/L) had approx a 3.5 X increased rate of CV death (vs [Chol-T] 200 mg/dL < 5.2 mmol/L)
Based on the Chicago Heart association detection project in industry, list:
1) Four factors assoc with 50% decrease in heart disease risk
2) Two factors assoc with 20% decrease in “ “ risk.
Am J Cardiol 2007:99(4):535-540
BR 22
Approx 50% reduction in heart disease risk:
1) Stop smoking (50% risk sudden MI)
2) >= 150 min moderate exercise/week (dec 35-55%)
3) Maintain ideal body weight/wast size (dect 35-55%)
4) 50% decrease in total cholesterol
Approx 20% decrease:
1) 6 mmHg decrease diastolic BP (16%; 42% dec CVA risk)
2) >= 5 servings fruit/vegetables/day (dec 20-25%)
Mn: Divergent (movie)
